深部浸润型子宫内膜异位症的手术治疗研究

发布时间：2018-02-14 16:20

本文关键词： 深部浸润型子宫内膜异位症手术治疗　出处：《复旦大学》2014年博士论文　论文类型：学位论文

【摘要】：前言深部浸润型内异症(deeply infiltrating endometriosis, DIE)指所有病灶浸润到腹膜下深度≥5mm内异症,可以位于盆腔不同部位,包括宫骶韧带、子宫直肠陷凹、阴道直肠隔内异症、膀胱内异症、输尿管内异症等。文献报道其发病率约为1-2。95%的DIE患者常伴有严重的疼痛。近十年来手术治疗方案成为DIE研究热点。本课题研究93例深部浸润型子宫内膜异位症患者的病例资料及预后,通过分析深部浸润型子宫内膜异位症的诊断、治疗以及疗效,旨在启发临床重视对深部浸润型子宫内膜异位症的诊断、合理制定手术治疗方案,加强患者围手术期及术后管理,为改善患者预后提供临床依据。第一部分深部浸润型子宫内膜异位症的临床诊断及手术方案研究目的：探讨深部浸润型子宫内膜异位症的临床诊断以及手术治疗方案制定。方法：选取2011年1月至2013年12月就诊于复旦大学附属妇产科医院并接受手术治疗的深部浸润型子宫内膜异位症患者93例,确定诊断标准、排除标准。手术治疗原则及方法分为DIE病灶根治性切除手术及DIE病灶非根治手术两种。对临床诊断依据以及手术治疗信息采用T检验、卡方检验及方差分析。结果：深部浸润型子宫内膜异位症在因子宫内膜异位症相关疾病而住院治疗病人中的比例为3.04%。93例深部浸润型子宫内膜异位症患者平均年龄34.99±7.15岁(24-55岁)。其中64.52%患者有明显痛经史,慢性盆腔疼痛30.11%,性交痛17.20%。病灶累及部位以宫骶韧带41.9%最常见。MRI病灶检出率80.6%。DIE合并内异症者CA125升高的阳性率较不合并者更高(66.5% VS 29.4%,P=0.021)。共93例患者接受手术治疗,90.3%患者采取腹腔镜手术,9例开腹手术,1例经阴道手术。病灶根治手术组的外科医师参与率显著高于非根治组(80% VS 7.9%,P0.001)。根治手术组同时合并妇科根治手术比例显著高于非根治组(16.4% VS2.6%,P=0.022)。并发症发生率根治组较非根治组更高((9.1 VS 0%,P0.001)。结论：深部浸润型子宫内膜异位症是内异症中较为复杂、严重的一种类型,临床诊断应综合疾病史、妇科检查以及影像学检查。腹腔镜手术是治疗疾病的最佳方式。病灶根治切除手术常需外科医师共同协作参与。第二部分深部浸润型子宫内膜异位症手术疗效研究目的：分析深部浸润型子宫内膜异位症的手术治疗效果以及围手术期综合管理。方法：采用VAS疼痛视觉模拟评分对患者术前术后的自身痛觉感受评分、WHOQOL-BREF评价术前术后生存质量、rAFS分期评估疾病严重程度、EFI评估生育功能、确定复发标准,对患者术前及术后治疗效果随访。主要研究围手术期治疗对深部浸润型子宫内膜异位症患者疼痛、生存质量、生育功能以及复发的影响。结果：成功随访85例DIE患者,平均随访时间18.3±8.7个月(3-36个月)。术后疼痛VAS评分较术前降低(0.89±1.6 VS 5.4±3.9,P0.001),且DIE根治切除手术的疼痛改善较非根治手术明显(5.6±3.9 VS 2.9±3.3,P=0.001)。术后生活质量全面提高。病灶根治组复发率较非根治组更低(3.9% VS 35.3%,P0.001)。27名生育要求者中不孕症占63%,累计妊娠率48.1%,术后平均妊娠时间7.0±4.0个月(3-18个月)EFI5妊娠率高于EFI≤4 (54% VS 0%, P=0.038),根治性病灶切除不提高妊娠结局。轻度盆腔内异症患者中病灶非根治组的生存质量自评总分改善更多(10.0±1.6 VS 6.8±2.7,P=0.034)。重度盆腔内异症患者中病灶根治组的疼痛评分(6.1±4.3 VS 2.9±3.4,P=0.002)、复发率(5.9%VS 36.7%,P=0.002)改善明显。DIE病灶根治切除同时行妇科根治术组年龄较妇科非根治组更大(43.5±6.7 VS 36.7±6.2, P=0.016)、疼痛改善更明显(8.7±2.2 VS 5.1±3.9,P=0.036)。非根治性手术术后使用GnRHa者疼痛改善较不用药者更明显(4.5±3.2VS 1.2±2.7, P=0.003)。GnRHa4-6支治疗组骨质疏松的发生率(25% VS 2.4%,P=0.011)较GnRHal-3支治疗组更高,但复发率更低(0% VS 14.6%,P=0.040)。结论：手术治疗能够改DIE善患者的疼痛症状并提高生活质量。EFI评分可以预测术后的生育功能改善情况。DIE病灶根治切除合并妇科根治术更适合于更年期患者。术后药物治疗能够预防疾病的复发。
[Abstract]:The deep infiltrating endometriosis (deeply infiltrating, endometriosis, DIE) refers to all lesions infiltration into the peritoneal endometriosis under depth more than 5mm, can be located in different parts of the pelvis, including uterosacral ligament, rectouterine pouch, rectovaginal septum endometriosis, bladder endometriosis, ureteral endometriosis. The reported incidence rate of about 1-2.95% DIE patients often accompanied by severe pain. Over the past ten years, surgical treatment has become the focus of DIE research. This research clinical data and prognosis of 93 cases of patients with deep infiltrating endometriosis, through diagnostic analysis of deep infiltrating endometriosis, treatment and curative effect, in order to inspire clinical attention the diagnosis of deep infiltrating endometriosis, reasonable surgical treatment, strengthen the perioperative and postoperative management, to provide clinical basis for improving the prognosis of patients. The first part of the deep Objective to study the clinical diagnosis and therapy of deep infiltrating endometriosis: making clinical diagnosis of deep infiltrating endometriosis and surgical treatment. Methods: from January 2011 to December 2013 the deep treatment in obstetrics and Gynecology Hospital of Fudan University and underwent surgery for infiltrating endometriosis patients in 93 cases, determine diagnostic criteria and exclusion criteria. The principle and method of surgical treatment of DIE lesions is divided into radical resection and radical resection of two non DIE lesions. Using T test for clinical diagnosis and surgical treatment of information, chi square analysis and variance. Results: deep infiltrating endometriosis in endometriosis related the disease and hospitalized patients in the proportion of 3.04%.93 cases of deep infiltrating endometriosis patients with mean age 34.99 + 7.15 years old (24-55 years old). 64.52% patients had obvious history of dysmenorrhea, chronic pelvic pain 30.11%, sexual pain 17.20%. lesions involving parts of the uterosacral ligament of 41.9% most common.MRI lesion detection rate of 80.6%.DIE with endometriosis were CA125 positive rate increased less with higher (66.5% VS 29.4%, P=0.021). A total of 93 patients underwent surgical treatment, 90.3% patients take laparoscopic surgery, 9 cases of laparotomy, 1 cases of vaginal surgery. Surgeons were radical surgery group participation rate was significantly higher than that in non eradication group (80% VS 7.9%, P0.001). Radical surgery group combined with gynecological radical operation was significantly higher than the proportion of non eradication group (16.4% VS2.6%, P=0.022). The complication rate of radical group non radical groups were higher (9.1 VS (0%, P0.001). Conclusion: deep infiltrating endometriosis is complicated in endometriosis, serious type, clinical diagnosis should be comprehensive medical history, gynecological examination and imaging Check. Laparoscopic surgery is the best way to treat the disease. The lesion resection surgery often require surgical physicians together. The second part involved in deep infiltrating endometriosis surgery clinical study objective: to analyze the effect of surgical treatment of deep infiltrating endometriosis and peri operative management. Methods: analog scale patients with preoperative and postoperative pain score by VAS its visual, WHOQOL-BREF evaluation of preoperative and postoperative quality of life, rAFS staging to evaluate the severity of the disease, EFI assessment of reproductive function, determine the recurrence criterion on the therapeutic effect of patients with preoperative and postoperative follow-up. The treatment of deep infiltrating endometriosis patients with pain. In the quality of life mainly study the perioperative period, fertility and recurrence effects. Results: follow-up of 85 cases of DIE patients, the mean follow-up time was 18.3 + 8.7 months (3-36 months). After the pain VAS score decreased (0.89 + 1.6 VS 5.4 + 3.9, P0.001), and DIE radical resection of pain improvement than non radical surgery significantly (5.6 + 3.9 VS 2.9 + 3.3, P=0.001). Improving the quality of life after surgery. The lesion eradication group the recurrence rate is lower (3.9% non radical group. 35.3% VS, P0.001).27 fertility requirements in infertility accounted for 63%, the cumulative pregnancy rate was 48.1%, the average postoperative pregnancy time was 7 + 4 months (3-18 months) the pregnancy rate of EFI5 is higher than that of EFI is less than or equal to 4 (54% VS 0%, P=0.038), radical resection does not improve pregnancy outcome of mild pelvic disease of lesions. The quality of life in patients with lesions of non radical group self rating scores improved more (10 + 1.6 VS 6.8 + 2.7, P=0.034). Severe pain lesions radical group of patients with pelvic endometriosis score (6.1 + 4.3 VS 2.9 + 3.4, P=0.002), the recurrence rate (5.9%VS 36.7%, P=0.002) Gai Shanming.DIE lesion resection at the same time for gynecology Radical surgery group than non gynecological age more radical group (43.5 + 6.7 VS 36.7 + 6.2, P=0.016), pain improved obviously (8.7 + 2.2 VS 5.1 + 3.9, P=0.036). Non radical surgery after GnRHa pain was improved without medicine more obvious (4.5 + 3.2VS 1.2 + 2.7. P=0.003).GnRHa4-6 treatment group, the incidence of osteoporosis (25% VS 2.4%, P=0.011) than the GnRHal-3 branch of treatment group is higher, but the recurrence rate is lower (0% VS 14.6%, P=0.040). Conclusion:.EFI can improve the quality of life score and pain surgery can change the DIE good patients can improve the situation of.DIE lesions with radical resection gynecological radical operation is more suitable for menopause patients in predicting postoperative reproductive function. Postoperative drug therapy to prevent recurrence of the disease.

【学位授予单位】：复旦大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R713.4

【相似文献】